‘If in Doubt, Sit Them Out’: Growing Concern About Heading and Brain Injury in Soccer – #NeverStop and #ConquerABI

In 2013, fans of English Premier League soccer club West Bromwich Albion stood in unity and applauded during the ninth minute of each match. It was a tribute to the man who had worn the team’s No. 9 shirt in the 1960s and 70s, the legendary center-forward Jeff Astle, who died in 2002.

During home games, Astle’s picture would appear on the scoreboard, alongside the caption, “If in doubt, sit them out,” a slogan commonly used to campaign for greater precautions against head injuries in soccer.

Scorer of the winning goal in the 1970 FA Cup final, Astle was renowned for his fierce header. He died at the age of 59, having suffered from early onset dementia. An autopsy revealed that his death was caused by brain damage stemming from repeated minor head traumas, and his case was looked into no further.

The 2013 “If in doubt, sit them out,” demonstration was part of a wider campaign to have Astle’s death re-examined. When that happened in 2014, Astle became the first former soccer player confirmed to have died from Chronic Traumatic Encephalopathy (CTE), a degenerative brain disease caused by repeated trauma – in this case, heading a soccer ball.

CTE has long been linked to more physically aggressive sports, such as boxing and American football, but never before had been seen in a soccer player, resulting from a staple part of the game that is commonly regarded as harmless.

In a documentary titled ‘Dementia, Football and Me,’ Astle’s daughter, Dawn, said, “His industry killed him. He was a (soccer) player, why did he have boxing brain?”

She continued, “He would try and get out of a moving car. It was a nervous wreck being around him. He’d go into the refrigerator and get a big scoop of butter with his hand and put it in his mouth.”

Since her father’s diagnosis, Dawn Astle has set up The Jeff Astle Foundation, which has campaigned for governing bodies in soccer to launch a full investigation into possible links between heading the ball and brain damage.

The movement has been gaining significant momentum. Last January, University College of London (UCL) published the first academic study into the risks of CTE in ex-soccer players. The study examined six former players with an average playing time of 26 years who had developed dementia before dying. Of those six, four had CTE.

Prior to the study’s publication, Astle’s was the only confirmed case of CTE in a soccer player.

Other efforts to gain insight into the issue include the University of Sterling’s ongoing study of 20 former players.

“Soccer has been a concern due to the heading of the ball that is involved in this sport, and this study indeed further raises concern for a link between soccer and CTE,” said Dr. Michael Alosco, a clinical neuropsychology fellow at Boston University’s CTE Center.

“We need to conduct more research in order to truly understand the risk of CTE and dementia in soccer,” he said. “The UCL study was in a very small sample size, and we don’t know what the risk for CTE from soccer is. Once we can understand risk factors for CTE and diagnose CTE in life, then we can start to conduct research on treatment and prevention.”

The BU CTE Center has previously focused much of its research into the disease’s links to American football. A study published in July 2017 found that 99 percent of donated brains of former National Football League players contained CTE.

The NFL has contributed $200 million to neurological research, and offers financial support to the families of former players who suffered from degenerative brain disease. Soccer has no such support system.

In an effort to raise awareness of the issue in the United Kingdom, former England striker Alan Shearer released the ‘Dementia, Football and Me’ documentary in November, which centers on his meetings with the families of victims of early onset dementia caused by heading the ball.

Two weeks after Shearer’s documentary was released, the English Professional Footballers Association (PFA) and Football Association (FA) commissioned the first official investigation into brain diseases’ links with soccer.

The study, titled “Football’s Influence on Lifelong Health and Dementia Risk” (FIELD), began this month and is led by Dr. William Stewart, the man who diagnosed Jeff Astle with CTE.

The study’s goal is to help clarify to what extent former players are at risk of developing brain disease.

Dr. Alosco emphasized that research was at an early stage, but has no doubt these repetitive blows to the head cause brain damage.

“All cases of CTE to date have had a history of repetitive head impacts (RHI). These RHI include concussions and sub-concussive injuries. If there is a history of RHI, regardless of whether it’s from heading the ball or player-to-player collision, it may have implications for CTE.”

In his documentary, Shearer said that it was the way he trained, not what happened in matches, that worries him. “I would practice (heading) over 100 times a day in training,” he said.

In 2015, U.S. Soccer became the first major national soccer body to place restrictions on heading. It prohibited children under the age of 10 from heading in practice and games. Heading regularly in practice is not allowed now until 14.

James Varley, who has coached children between the ages of 8 to 11 in Dorset, England, questioned the effectiveness of the ban. “It is important to remember that children who watch soccer on television will see adults heading the ball and want to do the same,” he said. “Even with the ban, children will continue to head the ball when playing without a supervisor.”

But Varley acknowledged he knew little about the medical consequences of heading.

“As a coach without medical training, I was unaware that a head collision with either the ball or another player’s head could cause serious underlying complications,” he said. “Instead, I was of the school of thought that if they wanted to carry on and seemed okay, they could.”

However, Dr. Alosco largely agreed with the purpose of the ban.

“We believe that exposure to RHI during peak neurodevelopment may increase one’s vulnerability to later-life thinking, memory, and mood problems,” he said. “Although much more research on this topic needs to be conducted to determine the short and long-term effects of youth football on the brain, it seems to make intuitive sense to limit potential brain injury during a time when the brain is undergoing tremendous maturation.”

Of five youth coaches and referees interviewed for this story, all said they had seen young players sustain head injuries, but none had received comprehensive training in diagnosing concussions.

Reuben Seyde has refereed for 10 years and is based in Boston. He deals with players ranging from 7 to 55 years old.

“I was briefly shown the symptoms of a concussion when I started,” he said. “I’ve seen players split their forehead from collisions with other player’s heads and players staring blankly after heading the ball.”

But more evidence will be needed to convince other coaches such as Malachi Ferguson, who has coached players from 13 to 18 in Sheffield, England.

“If research confirms a positive case to restrict heading, then it should be universally adopted, but my personal experience says that issues derived from heading the ball do not warrant this,” he said.

Unless more concrete links between heading the ball and brain disease are published, it seems unlikely this common cavalier attitude will change in the soccer world.

But some are heeding the warnings.

In September 2017, former Republic of Ireland striker Kevin Doyle announced his retirement due to recurring headaches at the age of 34.

Roy Keane, the Republic of Ireland assistant manager, did not mince words at a press conference.

“If you’re worried about the physical side of any sport, then play chess.”